By Leah Ida Harris

This article was originally published by Truthout

Massachusetts is now one of only two states that don’t use specialized courts to mandate forced psychiatric treatment.

On November 18, 2025, Massachusetts advocates gathered for hours at the State House as they have, year after year, to beat back yet another legislative proposal for involuntary outpatient commitment, or IOC. Involuntary outpatient commitment laws create a layer of specialized courts that use the so-called “Black Robe Effect,” which uses a judge’s authority to compel people with diagnoses of “severe mental illness” to accept mental health and/or substance use intervention against their will — in the form of psychotropic medication, drug testing, and invasive and time-consuming requirements.

While the specifics vary state by state, there are consequences for noncompliance. If the person does not follow their court-ordered treatment plan, they could be snatched by the cops, transported to a locked psychiatric facility for evaluation, and subject to ongoing state surveillance. It’s also not entirely clear where the offramp lies, as treatment orders can theoretically be renewed ad infinitum at a judge’s discretion.

Starting in 1999 in New York, the conservative think tank Treatment Advocacy Center rebranded involuntary outpatient commitment and began using the language of “assisted outpatient treatment (AOT),” a euphemized term erasing any reference to coercion. Along with the Treatment Advocacy Center, a coalition of police, psychiatrists, social workers, and family caregivers have pushed the laws through in 48 states and the District of Columbia. Massachusetts and Connecticut remain the only holdouts. Fern Fairchild, director of Massachusetts’ Wild Ivy Social Justice Network, part of the Wildflower Alliance, who has organized against forced treatment in both states, told Truthout that she attributes the lack of such laws in those two states, in large part, to “very strong survivors’ movements” aligned with disability rights and legal advocates.

As Bowen Cho wrote in a 2024 report for the Disability Rights Education and Defense Fund, entitled Equity for Whom? How Private Equity and the Punishment Bureaucracy Exploit Disabled People, “Carceral industries and their logics shapeshift and expand in response to public attention, often replacing one egregious system for another and calling it reform.”

Involuntary outpatient commitment is a perfect example of this shapeshifting. In Massachusetts, the law’s framing has been “forcewashed” — in other words, the carceral logic of it has been obscured beneath a language of care. The 2017-2018 version, entitled “An act establishing court ordered mental health assisted outpatient treatment” was further euphemized in 2021-2022 to refer to “assisted outpatient therapy,” with no mention of court orders. H.1801/S.1115, the bills currently before the Massachusetts legislature, now refer simply to a “continuum of care for severe mental illness,” and use the language of “critical community mental health services,” without mentioning “assisted outpatient treatment.”

“The mainstream view of AOT is generally that this mechanism is a ‘less restrictive’ alternative to inpatient hospitalization and means of connecting folks to care, who may be unhoused or ‘abandoned to the streets,’” Dr. Nev Jones, associate professor in the School of Social Work at the University of Pittsburgh, told Truthout via email. Jones is actively studying the implementation and impacts of AOT across multiple U.S. states.

The reality is often quite different from the hype. “Once on AOT orders, many individuals will remain unhoused if that’s where they’ve started — very few states guarantee housing to individuals on AOT,” Jones wrote.

A “Systemically Racist” Law

Involuntary outpatient commitment has often been likened to probation, and as Fairchild testified, is “systemically racist.” Clinicians diagnose Black people with schizophrenia, psychosis spectrum disorders, and other “severe mental illnesses” that make them eligible for coercive programs like involuntary outpatient commitment in far greater numbers than their white counterparts. This injustice persists due to clinicians’ documented racial bias and the white supremacist, colonial roots of the psychiatric profession itself.

Everywhere the involuntary outpatient commitment program has been implemented and studied, Black and Brown people are overrepresented. As legal scholar Victoria Rodríguez-Roldán wrote of the racially disparate outcomes of New York State’s outpatient commitment law, “the conclusion that any overrepresentation of minorities in the AOT program is harmful is inescapable.”

Fairchild’s testimony noted that involuntary outpatient commitment “would also likely impact other communities, such as trans people and immigrants who are also disproportionately diagnosed and are being targeted right now by the Trump administration.”

The 2025-2026 bill text further violates privacy and autonomy by redefining who can initiate a petition for court-ordered psychiatric intervention — expanding beyond the already massive net of spouses, parents and relatives, intimate partners, and legal guardians, to include “any responsible adult or individual partner in a substantive relationship.” Fairchild noted in her written testimony that this wide net could easily be misused “in furtherance of domestic abuse, giving these individuals another level of power to wield over victims.”

In the new bill, parole and probation officers are also granted the power to petition for court-ordered treatment. “The probation and parole systems are particularly punitive, regularly reincarcerating people for minor violations,” Fairchild testified. “Involving these systems and actors within them in IOC order petitions would likely result in even more psychiatric incarcerations resulting from violations of the conditions set forth in an IOC order.”

Eligibility criteria have also been expanded, broadening the justification for psychiatric force. This bill expands the definition of “gravely disabled,” a “vague term that could apply to anyone a mental health provider believes is not taking adequate care of themselves, including people who are unhoused,” according to written testimony by the Mental Health Legal Advisors Committee. Grave disability now includes people who “demonstrate psychosis” — and again, given the demonstrated racial bias in such assessments, this designation is deeply problematic.

Advocates noted yet another disturbing new criterion: “unlikely to voluntarily participate in outpatient treatment.” This allows the court to mandate treatment based on a prediction that people will not seek services on their own, and an assumption that they are incapable of making informed decisions. “The most common factor for this type of determination,” Fairchild wrote in her testimony, “Is that the person disagrees with the facility or provider’s recommendations. This gives facilities more pathways to override a person’s autonomy … where they disagree with their provider and do not consent to treatment.”

“Most people think AOT follows from a robust legal (court) process — like what many of us have seen in courtroom dramas,” Jones wrote. “Although this varies by state, there are places in which court hearings occur less than 10 percent of time, and/or otherwise amount to brief, six-to-ten minute ‘rubber stamping’ opportunities. In most states, individuals facing an AOT order have no right to a patient advocate and no right to a state-sponsored second opinion (psychiatrist or other evaluator of their choosing). This is most definitely not what most of us have in mind when we think about ‘procedural due process.’”  

Often missing from the conversation are the voices of people currently or formerly on these treatment orders. As journalist Rob Wipond reported, a 2023 Treatment Advocacy Center satisfaction survey is deeply biased, with clinicians cherry-picking respondents. Michael Simonson’s 2019 survey of 28 people impacted by treatment orders depicts a very different, mostly negative, picture of the experience.

As a researcher, Jones has spoken to many recipients of the treatment orders, as well as the judges and clinicians involved in implementing them. “Direct stories of what clients/service users are put through are deeply disturbing,” she wrote. “The level of neglect and abandonment of some on AOT orders can be gut-wrenching to hear.”

“While of course there are kind and thoughtful providers and staff,” she added, “Far too many individuals I’ve met invoke some of the worst, most harmful stereotypes and slurs I’ve ever come across. To see this level of prejudice normalized to this degree, is actually pretty terrifying. And it’s only a short stone’s throw … to Brian Kilmeade’s public advocacy for ‘lethal injections,’” referring to the disturbing comments made by the Fox News host who called on the state to execute unhoused people. “We’re not just talking about individual dehumanization, but dehumanization of an already ultra-marginalized group on a systems level.”

A Persistent Mischaracterization of the Problem

Pro-force advocates at the November 18, 2025, hearing, largely family caregivers, told horrific stories of trying to get timely and quality care for their adult children in Massachusetts’ labyrinthine systems of punishment, confinement, and abandonment. They shared devastating testimony of their loved ones’ encounters with police; of their children repeatedly rotating between psych wards, prisons, and the streets; and of loved ones who took their own lives.

At least two of the parents who testified noted that they already had access to every possible lever of state power, including Rogers guardianships, to compel their loved ones to follow prescribed treatment, yet they had failed to force their adult children to take medication.

Few ever bother to ask why individuals “go off their meds.” U.K. psychologist Dr. John Read, who has researched this question in-depth, has written in the past that respondents cite a lack of informed consent as well as an average of 11 adverse effects of antipsychotics and concerns with long-term health outcomes (well-founded, as these drugs can induce fatal cardiac events and metabolic disorders). Western biopsychiatry has produced dismal outcomes, including early mortality, for people with “severe mental illness” labels.

Family caregivers and medical authorities explain away any resistance to treatment using the controversial concept of “anosognosia,” a term inappropriately borrowed from neurology and often used interchangeably with “lack of insight,” to describe people who reject their diagnosis and medication or other treatments. While people can and do enter into various states, or say and do things that get labeled by systems and society as “lack of insight,” applying force and coercion in such circumstances only serves to increase mistrust and drive individuals further away from care, as many individuals testified at the hearing.

There are many paths beyond the extremes of force and abandonment to support people who would otherwise be eligible for coercive programs like involuntary outpatient commitment. Abolitionist organizers have long called for anti-carceral community crisis supports and providing the kind of care that people want, while ensuring that everyone’s needs for food, shelter, meaning, and human connection are met. Permanent supportive housing programs for disabled people, like Housing First, have long been a target of the right, and are on Trump’s chopping block.

Liberatory community supports already exist in Massachusetts, like Wildflower Alliance’s peer respites, a nonclinical, anti-carceral alternative to emergency rooms and locked facilities. A bill for expanding their availability in the state, including respites for BIPOC and LGBTQ+ people, is also currently before the legislature. Enduring Connections, a new program, also proposes to serve as an alternative to forced intervention, centering consistent, patient outreach led by peer workers. Psychiatric advance directives, health care proxies, self-directed care, and supported decision-making all allow people to exercise their legal capacity. There is no shortage of ideas, just a lack of political will to implement them.

“I wonder what’s possible if we stopped putting so much energy into going back and forth over this year after year, and truly focused on innovative, trust-building community supports,” testified Sera Davidow, co-founder of the newly formed Wildflower Roots and a longtime activist who has written and spoken extensively on involuntary outpatient commitment. “I hope we get to find out.”

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